title: Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure.
abstract: BACKGROUND
  We sought to examine the relationship between literacy and heart failure-related quality of life (HFQOL), and to explore whether literacy-related differences in knowledge, self-efficacy and/or self-care behavior explained the relationship.
  
  
  METHODS
  We recruited patients with symptomatic heart failure (HF) from four academic medical centers. Patients completed the short version of the Test of Functional Health Literacy in Adults (TOFHLA) and questions on HF-related knowledge, HF-related self-efficacy, and self-care behaviors. We assessed HFQOL with the Heart Failure Symptom Scale (HFSS) (range 0-100), with higher scores denoting better quality of life. We used bivariate (t-tests and chi-square) and multivariate linear regression analyses to estimate the associations between literacy and HF knowledge, self-efficacy, self-care behaviors, and HFQOL, controlling for demographic characteristics. Structural equation modeling was conducted to assess whether general HF knowledge, salt knowledge, self-care behaviors, and self-efficacy mediated the relationship between literacy and HFQOL.
  
  
  RESULTS
  We enrolled 605 patients with mean age of 60.7 years; 52% were male; 38% were African-American and 16% Latino; 26% had less than a high school education; and 67% had annual incomes under $25,000. Overall, 37% had low literacy (marginal or inadequate on TOFHLA). Patients with adequate literacy had higher general HF knowledge than those with low literacy (mean 6.6 vs. 5.5, adjusted difference 0.63, p < 0.01), higher self-efficacy (5.0 vs. 4.1, adjusted difference 0.99, p < 0.01), and higher prevalence of key self-care behaviors (p < 0.001). Those with adequate literacy had better HFQOL scores compared to those with low literacy (63.9 vs. 55.4, adjusted difference 7.20, p < 0.01), but differences in knowledge, self-efficacy, and self-care did not mediate this difference in HFQOL.
  
  
  CONCLUSIONS
  Low literacy was associated with worse HFQOL and lower HF-related knowledge, self-efficacy, and self-care behaviors, but differences in knowledge, self-efficacy and self-care did not explain the relationship between low literacy and worse HFQOL.
authors.affiliation: UCLA School of Nursing, University of California, Olive View-UCLA Medical Center Los Angeles, 700 Tiverton Ave., 4-242 Factor Blvd., Los Angeles, CA 90095, USA. aoconnel@sonnet.ucla.edu
authors.forename: Aurelia
authors.initials: A
authors.lastname: Macabasco-O'Connell
authors.forename: Darren A
authors.initials: DA
authors.lastname: DeWalt
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Broucksou
authors.forename: Victoria
authors.initials: V
authors.lastname: Hawk
authors.forename: David W
authors.initials: DW
authors.lastname: Baker
authors.forename: Dean
authors.initials: D
authors.lastname: Schillinger
authors.forename: Bernice
authors.initials: B
authors.lastname: Ruo
authors.forename: Kirsten
authors.initials: K
authors.lastname: Bibbins-Domingo
authors.forename: George M
authors.initials: GM
authors.lastname: Holmes
authors.forename: Brian
authors.initials: B
authors.lastname: Erman
authors.forename: Morris
authors.initials: M
authors.lastname: Weinberger
authors.forename: Michael
authors.initials: M
authors.lastname: Pignone
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D057220:Health Literacy / Q000592:standards; D006333:Heart Failure / Q000523:psychology* / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011788:Quality of Life / Q000523:psychology*; D012648:Self Care / Q000523:psychology* / Q000592:standards; D012959:Socioeconomic Factors